More than 8.5 million Americans are affected by peripheral arterial disease (PAD), and Alabama has one of the highest rates of the disease and of amputations, which result from critical limb ischemia developed from PAD.
For decades, surgery was the cornerstone for revascularization in these patients, but percutaneous endovascular therapy has largely replaced surgery as a first choice for treating PAD, and the femoral artery at the groin has been the predominant access site for this treatment. However, recent advances in equipment and techniques have allowed physicians to access the lesions from the pedal arteries in the foot and the radial artery in the wrist with low risk and great success.
"Femoral artery access has a higher risk of bleeding and patient discomfort due to prolonged bed rest, so the radial artery has already become the predominant access site for most coronary procedures treating obstructive disease in the heart," says interventional cardiologist Abilash Balmuri, MD, FACC, of Heart South Cardiovascular Group in Alabaster. "The extension of this technology to endovascular intervention is helping patients manage their PAD. The benefits of radial access for patients include reduction in bleeding complications and infection rates as well as increased patient satisfaction and reduced length of stay. Facilities have reduced costs due to shorter post procedure stays, and most patients are discharged within a couple of hours following the procedure."
Balmuri has successfully performed the first radial to peripheral intervention at the Heart South Vascular Institute. "During the procedure, we access the peripheral arteries in the lower extremities from the wrist which decreases complication risk and post procedure recovery time, especially in patients with difficult femoral access," he says. "This new technique benefits from availability of technology that uses longer wires, atherectomy devices, and further-reaching balloons and stents that will revolutionize the way peripheral vascular disease is treated in the future."
One of the main complications of femoral artery procedures is increased risk of bleeding because the artery is larger and located deeper in the groin area. With this procedure, the patient can have discomfort from a doctor or nurse holding pressure to the groin to close the access site, and prolonged bed rest for up to six to eight hours is necessary. "These issues are eliminated with the radial artery procedure. The bleeding risk is low, because the radial artery is superficial and no bed rest is needed," Balmuri says.
Recent feasibility studies with the new transradial technology have been successful with 90 to 95 percent positive outcomes. "Non-healing ulcers can lead to amputation without intervention. With endovascular therapy, certain patients are great candidates for lower risk access from the radial artery in the wrist or the pedal arteries in the foot," Balmuri says. "Pedal access using the anterior tibial or posterior tibial arteries has also revolutionized our ability to treat severe disease where amputation was unavoidable in the past."
There are some drawbacks to the trans-radial access. The radial artery is small so the surgeon cannot upsize the equipment when certain larger arteries have to be treated. And reaching arteries farther below the knee can pose challenges. "Radial access potentially can replace the need for femoral access in a large subset of patients, but it is not suitable for every procedure," Balmuri says. "Also, a lack of dedicated equipment needed for the radial to peripheral procedures prevents many hospitals from offering the approach. At this point, the procedure itself is suitable for most patients, and we at the Heart South Vascular Institute are early adopters of this technology. I have had several patients who had the groin access treatment in the past, and they are thankful to have access to a safer procedure with less discomfort."
While the transfemoral access currently remains the gold standard for endovascular therapy, the transradial access is the new frontier. Currently, utilization for this access is less than five percent of all procedures. "In the future, I think half of these procedures can be done by the transradial route, but we will still need the traditional access," Balmuri says. "We now have a variety of options to choose from, including femoral, radial and pedal access. PAD is a debilitating disease, and critical limb ischemia has higher mortality than most cancers. If we can raise awareness in the medical community about the disease in general and transradial arterial access in particular, I believe we can help many of these patients before it's too late."